Leprosy Mailing List – September 25, 2015
Ref.: (LML) Protecting Indians from leprosy
From: Joel Almeida, London and Mumbai
Dear Pieter,
Anti-microbial treatment and anti-inflammatory treatment are like the warp and woof of the safety net which protects Indians against the deformities of leprosy. There are some holes in the safety net.
The suppression of active case finding since 2005 has led to several thousand Indians each year suffering visible deformity before the diagnosis of leprosy.
Further, as many as 50% of newly treated MB patients in India (33,000 patients per year) may be estimated to develop serious but avoidable nerve damage, despite MDT. Over 300,000 Indians are likely newly to develop visible deformity during the next 10 years, despite MDT.
Both these holes in the safety net can be repaired.
1) Active case detection can be aided by skin camps and similar detection drives, where all people with skin complaints are served. This allows leprosy cases to be detected in less stigmatising ways.
2) Nerve damage occurs mostly during the first 2 years after the start of MDT. This damage most often follows “silent” neuritis, of which even the patient is unaware.
Nerve damage can be better prevented by monthly monitoring of nerves by skilled leprosy workers, with prompt anti-inflammatory treatment where required. This skilled monthly monitoring is required among at least MB patients during the first 2 years after the start of MDT.
India could re-introduce a cadre of skilled, mobile leprosy workers who travel to meet MB patients near where they live. These skilled workers would cover the population served by several health centres (in cities, this amounts to a population of millions). They would monitor the nerves of MB patients during the first 2 years after the start of MDT, and keep records of nerve function. This would enable prompt anti-inflammatory treatment for neuritis, even silent neuritis.
I recently met Dr. Raghuram Rajan, governor of the Reserve Bank of India (RBI). When asked, he asserted that spending on effective health interventions is investment, not expenditure. Such investment is essential for continued economic growth in India. This puts the ball in our court. If we put a convincing case for intensified interventions against leprosy, adequate investment is likely.
The incidence rate of leprosy in India could eventually decline if extreme poverty is alleviated. Such a decline was observed in Norway without effective anti-leprosy drugs and in Shandong province, China, with only dapsone. Alleviation of extreme poverty is not a certainty, despite the impressive growth rate of the Indian economy.
The Table: Newly detected leprosy cases in India by deformity and type
Year | | Newly detected cases /10,000 population / yr | | % with visible deformity among newly detected cases | | Newly detected cases with visible deformities / million population / yr | | Newly detected MB cases / 10,000 population / yr |
2008-9 | | 1.119 | | 2.80 | | 3.133 | | 0.5416 |
2009-10 | | 1.093 | | 3.10 | | 3.388 | | 0.5301 |
2010-11 | | 1.048 | | 3.10 | | 3.249 | | 0.5093 |
2011-12 | | 1.035 | | 3.00 | | 3.105 | | 0.5072 |
2012-13 | | 1.078 | | 3.45 | | 3.719 | | 0.5381 |
2013-14 | | 0.998 | | 4.14 | | 4.132 | | 0.5138 |
2014-15 | | 0.973 | | 4.61 | | 4.486 | | 0.5139 |
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source: NLEP (National Programme) progress reports | ||||||||
The table shows that, in India, the incidence rate of newly detected MB (multibacillary) cases is apparently not declining. This indicates the trend in the underlying incidence rate of leprosy. The ANCDR (annual new case detection rate of all types of leprosy) is less reliable because of self-healing cases. The incidence rate of newly detected cases with visible deformity is apparently increasing; driven partly by delays in diagnosis and partly by the underlying incidence rate of leprosy.
New tools and approaches could help interrupt the transmission of leprosy. That is not certain, since M. leprae can survive for at least 5 months in the shade in India; and resume multiplication when re-introduced into a host. Extra-human reservoirs such as amoebae could permit indefinite survival and replication of M.leprae. Besides, MB patients usually are infectious for a long period before they show any signs of leprosy.
We can try new tools and approaches, but our hopes need to be tested: the more rapidly the better. Even as we hope for game-changing outcomes, we need to be prepared for disappointment.
There is no substitute for plucking the low-hanging fruit in leprosy control:
1) Active case detection
2) MDT
3) Monthly monitoring of nerves among MB patients during the first 2 years after the start of MDT, with prompt anti-inflammatory treatment when required.
Elimination of leprosy services has exacted a heavy price from the people of India, in terms of avoidable deformity. This can be remedied.
We can save over 300,000 Indians from visible deformity over the next 10 years, using the tools already available. Let’s make it happen.
Regards,
Joel Almeida
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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